What are the AACE/ACE guidelines on HRT for the treatment of menopausal symptoms?

Updated: Jun 06, 2018
  • Author: PonJola Coney, MD; Chief Editor: Richard Scott Lucidi, MD, FACOG  more...
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In August 2017, the American Association of Clinical Endocrinologists and the American College of Endocrinology released a position statement emphasizing an individualized approach to treatment of menopausal symptoms. The guidelines included the following recommendations [99, 100] :

  • Use of menopausal hormone therapy in symptomatic postmenopausal women should be based on consideration of all risk factors for cardiovascular disease, age, and time from menopause.

  • Use of transdermal, as compared to oral, estrogen preparations may be considered less likely to produce thrombotic risk and perhaps the risk of stroke and coronary artery disease.

  • When the use of progesterone is necessary, micronized progesterone is considered the safer alternative.

  • In symptomatic menopausal women who are at significant risk from the use of hormone replacement therapy (HRT), the use of selective serotonin reuptake inhibitors and possibly other nonhormonal agents may offer significant symptom relief.

  • AACE does not recommend use of bioidentical hormone therapy.

  • AACE fully supports the recommendations of the Comité de l'Évolution des Pratiques en Oncologie regarding the management of menopause in women with breast cancer.

  • HRT is not recommended for the prevention of diabetes.

  • In women with previously diagnosed diabetes, the use of HRT should be individualized, taking into account age and metabolic and cardiovascular risk factors.

In November 2015, The UK National Institute for Health and Care Excellence (NICE) issued guidelines on menopause that recommend that doctors [101, 102] :

  • Offer women hormone-replacement therapy (HRT) for hot flushes and night sweats after discussing risks and benefits.
  • Consider HRT to ease low mood that occurs as a result of menopause and consider cognitive behavioral therapy to alleviate low mood or anxiety.
  • Explain that estrogen-only HRT has little or no increase in the risk of breast cancer, while HRT with estrogen and progestogen can be associated with an increase in the risk of breast cancer, but any increased risk reduces after stopping HRT. Specifically, it says there will be 17 more cases of breast cancer per 1000 menopausal women in current HRT users over 7.5 years (compared with no HRT).
  • Understand that HRT does not increase cardiovascular disease risk when started in women aged under 60 years and it does not affect the risk of dying from cardiovascular disease. Also ensure that women with cardiovascular risk factors are not automatically excluded from taking HRT.
  • Refer women to a menopause specialist if there's no improvement after trying treatments.

In 2014, The North American Menopause Society released recommendations on the clinical care of midlife women that address key issues specific to menopause, along with more general issues related to women’s sexual function, cognition, cardiovascular health, thyroid disease, and cancers. [103, 104]  Topics covered included the following:

  • Use of hormonal replacement therapy in perimenopausal and postmenopausal women

  • Use of bazedoxifene combined with conjugated estrogen for the treatment of vasomotor symptoms and osteoporosis prevention in women with a uterus, use of low-dose paroxetine for vasomotor symptoms, and use of ospemifene for dyspareunia

  • Use of estrogen therapy alone in women without a uterus and use of estrogen plus progesterone therapy in women with a uterus

  • The benefits of hormone replacement therapy for treating vasomotor symptoms, which outweigh the risks in most healthy, symptomatic women who are younger than 60 years or within 10 years of their final menstrual period

  • Use of hormone replacement therapy in women with primary ovarian insufficiency, in whom the benefits of therapy outweigh the risks until the average age of natural menopause

In May 2013, the British Menopause Society and Women's Health Concern issued updated guidelines on the use, benefits, and risks of hormone replacement therapy (HRT). [105, 106] Key recommendations include individualization of HRT, annual risk/benefit assessment, use of HRT in women with premature ovarian insufficiency, an exploration of pharmacologic alternatives to HRT, and a discussion of the benefits of phytoestrogens.

In January 2014, the American College of Obstetricians and Gynecologists released an updated Practice Bulletin on the treatment of vasomotor symptoms of menopause and vaginal atrophy. [107] Recommendations include the following:

  • Systemic hormone therapy with estrogen or estrogen plus progestin is the most effective treatment for vasomotor symptoms.

  • Low-dose estrogen and ultra-low systemic doses of estrogen have a better adverse effect profile than standard doses.

  • Alternatives to hormone therapy for vasomotor symptoms include selective serotonin reuptake inhibitors, selective serotonin and norepinephrine reuptake inhibitors, clonidine, and gabapentin.

  • Use of progestin alone, testosterone, compounded bioidentical hormones, phytoestrogens, herbal supplements, and lifestyle modifications are not supported by the data.

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